Gynaecological problems in women with rheumatoid arthritis

by Dr. Archana Ravindra Shinde

Our immune system protects us from diseases.Ideally, antibodies, which are part of the immune system, recognize and destroy infections like bacteria and viruses so we do not get sick. To do this successfully, our body must be able to distinguish between "self" and "non-self" (e.g. bacteria and viruses).

Autoimmune diseases occur when the body misinterprets "self" and "non-self", resulting in the destruction of its own cells. The causes of autoimmune disease are unclear. It appears that multiple genes work together to make an individual vulnerable and ultimately, a trigger occurs that disrupts proper functioning of the immune system.

The trigger may be an infection, medication, or environmental exposure, but often it is unknown.

Approximately 5% of the population in Western counties have autoimmune diseases. Of people with autoimmune conditions, 75% are women. The two most common conditions are rheumatoid arthritis and autoimmune thyroiditis. Other types, while relatively rare, include multiple sclerosis, psoriasis and lupus.

Role of gynaecologist

Although primary care clinicians and Gynaecologists might not see large numbers of women with RA in their practices, the demographics related to this disease make it clear that they will undoubtedly encounter some. The overall prevalence of RA is approximately three times greater in women than in men. It is not understood why women are more likely to develop rheumatoid arthritis than men. However, research continues in this area and there are several theories that exist.

The most prominent theory about the development of rheumatoid arthritis being more common in women is associated with changes in the levels of sex hormones, including estrogen and progesterone. These sex hormones have critical roles in the inflammatory response and in the overall regulation of the immune system.

Gynaecological problems are as common in rheumatoid arthritis patients as in the general population.

They can be categorised into two groups :

• peri-menopausal
• menopausal

The most common gynaecological problems in perimenopausal age group are :

• Abnormal bleeding,
• Vaginal discharge,
• Dysmenorrhoea (usually of secondary type)
• Chronic pelvic pain.

Whereas those commonly seen in post menopausal women are

• displacement of the genital tract (i.e prolapse)
• osteoporosis
• malignacy
• Post menopausal bleeding.
Pain and depression are equally found in both the age groups.

Abnormal bleeding : It is a wide spectrum comprising of amenorrhoea, dymenorrhoea, oligomenorrhoea menorrhagia, to post menopausal bleeding.

The typical menstrual cycle lasts 28 days, but a range between 21 to 45 days is considered normal. Abnormal bleeding is very common, affecting most women at some time. Any vaginal bleeding that does not occur at routine intervals can be considered "abnormal". Typically if you have had three abnormal cycles in the preceding six months, it is wise to consult a doctor. The quantity of blood loss considered abnormal varies from women to women. If bleeding produces clots or if you soak through more than three tampons in a 24 hour period, consider this excessive. Most important, a peristent change in your bleeding pattern should warrant medical attention.

One of the contributory reason for abnormal bleeding other than the sex hormones is due to the anti rheumatoid drugs used i.e steroids and aspirin which tend to thin the blood.

Amenorrhoea : It is usually the general ill-health that is the underyling reason. Underweight women frequently have amenorrhoea. Weight and height measurements are used to determine accurately if there is a weight problem. From these measurements you can calculate your body mass index (BMI). Ideally this should be between 20 and 25. Body fat plays an important part in the chemistry of the sex hormones.

Vaginal discharge : is one of the more common reasons for a women to consult her doctor. A troublesome increase in vaginal discharge may need assesment. An offensive odour, vaginal and vulval (external) irritation or soreness are common accompanying symptoms when there is infection.

Chronic Pelvic Pain : Is arbitrarily defined as three months or more of constant or intermittent pelvic pain. Spasm or rigidity of muscles specially those of vertebral column suggests orthopedic, neurologic or rheumatic lesion.

Sexual Problems : Previous research has identified two main problems of sexuality in female rheumatoid arthritis (RA) patients : difficulties in sexual performance and dimunition of sexual desire and satisfaction. More than 60% of female RA patients experience variable degrees of sexual disability and diminished sexual desire and satisfaction. Difficulties in sexual performance are related more to overall disability and hip involvement, while diminished desire and satisfaction are influenced more by perceived pain,age and depression.

Rheumatoid arthritis in pregnancy : Therapy in pregnancy constitues an important consideration. Although RA symptoms usually improve during pregnancy, prenatal maintenance therapy can be challenging. Teratogenicity is a concern for certain DMARDs, and safety data for other agents are limited. In patients trying to conceive, Methorexate (MTX) and leflunomide should be avoided. Ideally, MTX should be discontinued at least 3 months prior to conception. Leflunomide should not be given to women of reproductive age who are not using reliable contraception, and it should be discontinued at least 2 years prior to conception. Otherwise, leflunomide must be eliminated by cholestyramine chelation therapy as soon as pregnancy is planned and women should wait at least 3 menstrual cycles before attempting pregnancy. Minocycline is also contraindicated during pregnancy, according to the latest ACR recommendations.

As optimal pregnancy outcome is achieved when disease activity is limited, pregnant women with RA must be monitored closely to balance remission maintenance against fetal risk. This sometimes involves the use of DMARDs that have some potential fetal risks. Sulfasalazine, azathioprine, cyclosporine and hydroxychloroquine, are considered relatively safe in clinical practice for use during pregnancy. However, given the limited and sometimes conflicting evidence, the new ACR guidelines made no specific recommendations regarding the use of biologic agents in pregnancy. Current practice is to withhold them after pregnancy is confirmed, despite some reports of successful outcomes while using these agents.

Breast feeding : With regard to breast feeding the ACR made no specific recommendations beyond contraindicating the initiation or resumption of leflunomide, MTX, and minocycline use during lactation. In clinical practice, though, many rheumatologists feel it is safe to continue hydoxychloroquine and sulfasalazine throughout breast feeding, but not azathioprine or cyclosporine. Biologic agents, especially rituximab and abatacept,are usually avoided during breast feeding.

Postmenopausal problems :


• displacement of the genital tract (i.e.prolapse),
• osteoporosis,
• malignancy,
• Post menopausal bleeding.

Beyond their reproductive years, women with RA are at increased risk for complications such as cardiovascular disease (CVD) and osteoporosis. Several studies have shown a higher risk of myocardial infarction and stroke in patients with RA, independent of the traditional risk factors. One recent meta-analysis found a 50% higher risk of CVD mortality in patients with RA compared with the general population, possibly due to the chronic inflammatory environment and / or drug side effects.

Higher disease activity, longer duration of RA, and chronic use of certain drugs ( e g glucocorticosteroids, NSAIDs) are factors associated with higher CVD risk in the setting of RA. To reduce CVD morbidity and morality, primary prevention should be optimized with comprehensive management of the conventional CVD risk factors, along with control of the inflammatory RA milieu and avoidance of drugs known to contribute to risk.

Osteoporosis is another major health concern for women with RA. Although glucocorticosteroid use is a well-known cause of osteoporosis, bone loss is also prevalent in patients with severe RA who have never received glucocorticosteroids. In fact, osteoporosis is the principal bone abnormality of RA, affecting both cortical and trabecular bone and increasing the risk of fractures and fracture fixation failure. In the absence of clear guidelines, early screening, primary prevention, and effective treatment of osteoporosis in women with RA are essential with premenopausal therapy of necessary. measures include tapering of glucocorticosteroid use, when possible, plus calcium and vitamin D supplementation.

Conclusion

Like most autoimmune diseases, RA has an increased prevalence among women. Pregnant women and their fetuses may be at risk of harm from certain DMARD; with insufficient safety data available for the newer DMARDs in pregnancy, their use should be individually tailored for each patient.

Counselling the pregnant patient about the possible impact of RA and its therapy is an essential part of comprehensive management. Postmenopausally, women with RA are at higher risk for CVD and osteoporosis, necessating close monitoring, preventive measures and early treatment.